PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
WELCOME
To All Personnel Completing This Electronic Personal History Questionnaire:

This letter contains important information regarding your application for unescorted access to Duke Energy nuclear facilities. Duke Energy administers an unescorted access program that conservatively applies standards of reliability and trustworthiness, and provides the highest possible assurance of a drug/alcohol free environment in its nuclear facilities.

Adhering to the guidelines below as well as the other instructions provided during your processing will facilitate efficient processing. You must fill out your electronic application for unescorted access fully and honestly. If you don't understand a question, obtain clarification. Please pay particular attention to the specific instructions provided on the application for each Section. For example, if you are required to list ALL legal actions since your 18th birthday, then do list ALL of your legal action history since your 18th birthday.

We also ask that you reconsider your application based on the following:
  • We will verify virtually all information you provide. Often "denials" result from falsification or omission of information. Many times the item omitted or falsified would not have resulted in a denial. If you falsify or omit information, you will be subject to denial of access from our nuclear facilities.
  • If you have had a recent positive drug or alcohol test or a recent history of illegal drug use or possession of drugs, it is unlikely that you will be granted access.
  • If you have a pending legal action(s), your request may be delayed until the legal action(s) is resolved.
  • If you have had a recent felony conviction, it is unlikely you will be granted access.
  • If you have multiple recent misdemeanor convictions in the past couple of years, it is unlikely you will be granted access.
  • If you fail to fully cooperate during the screening process, it is unlikely you will be granted access.
  • Refusal to consent for the background investigation or sharing of personal information with other licensees or contractor/vendors is also sufficient cause for denial of unescorted access.

The list above is not inclusive. Items such as credit, character and reputation, psychological suitability, legal actions, and problems with past employers are also considered. Our mission is to provide a safe and secure working environment for personnel in our nuclear plants. Your cooperation during the screening process is vital, and demonstrates that you share this commitment. If you have any questions, please contact a member of the Plant Access Authorization (PAA) staff or your employer.

Moving Around the PHQ
Each page contains buttons to help you navigate through the PHQ. The "Previous" button will take you to the previous page of the PHQ. The "Next" button will take you to the next page. If you click the "Next" button and the page does not change it means that there is an error on the page.

Handling Errors
The fields on the PHQ are validated when you leave a field or when you navigate away from the page. Remember, you will not be able to move on to the next page of the PHQ until all errors on the current page are resolved. Fields that have errors are colored red. Clicking in a red field will display a message that will help you fix the error.

Getting Help
Each page of the PHQ has a button labeled "Help." Clicking that button will open a new window (or tab) and you will see help related to the current page of the PHQ.

If you have any questions regarding the completion of your PHQ, please contact your Coordinator or an Access Authorization staff member prior to submitting the forms.

By my signature below, I certify that I have read and understand the information contained on this page.

Applicant's Full Name
SECURE ID
Date Signed

Click Sign button to electronically sign
PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
OVERVIEW
All information provided will be treated as PERSONAL-CONFIDENTIAL and observed only by persons with an authorized NEED-TO-KNOW.
In order to meet the requirements of the Nuclear Regulatory Commission (NRC), the licensee or approved contractor/vendor (approved C/V) to which you are applying for unescorted access authorization (UAA), unescorted access (UA), fitness-for-duty authorization (FFDA), construction access (CON) and/or requires that you consent to undergo a background screening process. The purpose of the screening process is to determine your trustworthiness and reliability to work within the protected and vital areas of a nuclear power plant (NPP). Information from this form will be used to conduct a background investigation for access authorization purposes as required by the NRC.

You must provide all information requested in a complete and accurate manner. Your signature on the document is your certification that the information you have provided is complete and correct. Providing deliberate or willful misleading statements to any NPP with the intent to gain access is a violation of Federal regulations. Any misrepresentation, deliberate misstatement, falsification or willful omission may constitute cause for denial or revocation of UAA/UA/FFDA/CON/SGIA. Failure to report and list reasons for any previous suspension, revocation or denial of UAA/UA/FFDA/CON/SGIA at a NPP or other entity subject to either the NRC UAA/UA/FFDA/CON/SGIA regulations may be sufficient cause for denial or revocation of UAA/UA/FFDA/CON/SGIA. If such an instance is detected Duke Energy is required to advise the NRC. The NRC may investigate you and, if appropriate, criminal and civil sanctions may be imposed against you if deemed material by the NRC. When such instances have previously occurred, the result has been a lengthy (five-year) or permanent exclusion from work at nuclear power plants in the United States.

The facts concerning your criminal history or fitness-for-duty record may be subject to interpretation due to varying categorizations of similar offenses between States. It is therefore required that you disclose all information that has any potential for being considered as derogatory to minimize the likelihood of discrepancies between the information you provided and that obtained from other sources. All information requested is needed for the purpose established by NRC regulations or Orders. In some of the sections of the PHQ you are required to provide your personal information; in other sections you will be required to acknowledge that you understand certain on-going requirements or personal responsibilities. The information requested may include any or all of the following topics: verification of identity, self-disclosure data, employment/unemployment history (including military service and/or education in lieu of employment), criminal history, credit history, character references, residences, and fitness-for-duty history. When not in use, your written information is stored in a secure environment, which may include being electronically placed in a secure database, to prevent unauthorized disclosure of personal information.

The licensee requesting the completion of this document may require your Social Security Number (SSN), the last 4 digits of your SSN and/or provide you with a protected unique identification number or password linked to you for use on this form. The NRC requires the verification of true identity and you will be required to disclose your SSN that will be maintained for the same period as your personal information contained on this PHQ.
PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
NOTIFICATION OF LEGAL ACTION
Individuals applying for, certified for, granted or maintaining Unescorted Access Authorization (UAA), or Unescorted Access (UA), or Fitness-for-Duty Authorization (FFDA), or construction access (CON), or safeguards information access (SGIA) at nuclear power plants must report legal actions from the time the individual signs the Personal History Questionnaire (PHQ) up to and including the time that the individual UAA/UA/FFDA is terminated. Legal actions will be judged based upon the potential to impact upon your trustworthiness. This is part of the Behavioral Observation Program (BOP).

ANY DELIBERATELY FALSIFIED OR OMITTED INFORMATION WILL RESULT IN THE DENIAL OF UNESCORTED ACCESS AND, UNDER 10 CFR 50.5 (DELIBERATE MISCONDUCT) MAY BE SUBJECT TO NRC ENFORCEMENT ACTION IN ACCORDANCE WITH PROCEDURES IN 10 CFR PART 2, SUBPART B

IF YOU DESIRE A CONFIDENTIAL INTERVIEW UPON PROVIDING INFORMATION REGARDING CRIMINAL HISTORY YOU MUST CONTACT ACCESS AUTHORIZATION

To comply with regulatory requirements, you are required to report ANY legal action (except minor traffic and civil offenses), to your supervisor/designee and Plant Access Authorization (PAA) as soon as practical, but no later than your first day reporting to work or arrival upon company property following the legal action and in writing to Plant Access Authorization (PAA) using the legal action reporting form. Legal Action documentation must be provided no later than your first day reporting to work or arrival upon company property following the legal action or as directed by the PAA representative. It is expected that you will report the legal action prior to entering the Protected Area. Failure to report a legal action as required may result in denial, suspension, revocation, or withdrawal of UAA/UA or FFDA, and disciplinary action up to and including discharge.

A legal action is defined as:

  • A formal action taken by a law enforcement authority or court of law, including being held, detained, taken into custody, charged, arrested, indicted, fined, forfeited bond, cited, or convicted for a violation of any law, regulation or ordinance.
  • This includes felony, misdemeanor, serious traffic offenses, serious civil charges or military charges but does not include minor misdemeanors such as parking tickets or minor civil actions such as zoning violations or minor traffic violations such as moving violations when the individual was not physically taken into custody.
  • It also includes the mandated implementation of a plan for treatment or mitigation in order to avoid a permanent record of an arrest or convictions in response to the following:
       1. The use, sale or possession of illegal drugs (including controlled substances determined to be illegal under federal law, such as marijuana, but deemed legal under a state law);
       2. The abuse of legal drugs or alcohol; or
       3. The refusal to take a drug or alcohol test.
  • This does not include minor misdemeanors such as parking tickets, minor civil actions, such as zoning violations, or minor traffic violations such as moving violations when the individual was not physically taken into custody, provided the legal action did not include use, sale, or possession of illegal drugs; abuse of legal drugs or alcohol; or refusal to take a drug or alcohol test.


By my signature below, I certify that I have read this notification and understand my obligation to report legal actions from the signing of this document until authorization is terminated. I also understand that any falsified or omitted information will result in the denial of access, and any other consequences imposed by Federal Law (10 CFR 50.5 "Deliberate Misconduct").

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PADS CONSENT
1. Duke Energy has my consent to:
 
   a. Collect personal information about me in order to verify the information's accuracy;
   b. Conduct a background investigation (BI) in accordance with U. S. Nuclear Regulatory Commission (NRC) regulations to verify information I have provided on a Personal History Questionnaire and other information, including social media, as necessary;
   c. Take my fingerprints and associated information/biometrics. In addition, I understand that:
 
   1) The Federal Bureau of Investigation's (FBI's) acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of my application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing my fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of my application for unescorted access authorization (UAA) or fitness for duty authorization (FFDA).
   2) Certain determinations, such as UAA/FFDA, may be predicated on fingerprint-based background checks. My fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing my fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. In addition to the FBI's NGI, my fingerprints and associated biographic identifiers may be compared against fingerprints in the Department of Homeland Security's (DHS') Automated Biometric Identification System (IDENT) or replacement system Homeland Advanced Recognition Technology (HART). Comparison of my fingerprints and biometric data against information in the DHS IDENT/HART systems will be run on a search-only basis, with no retention or enrollment of my information in those systems. The FBI may retain my fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, my fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.
   3) During the processing of my application and for as long thereafter as my fingerprints and associated information/biometrics are retained in NGI, my information may be disclosed pursuant to my consent, and may be disclosed without my consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.
   d. Retain personal information provided for investigation; and
   e. Transfer information from other licensees, or approved contractor/vendors (approved C/V) as necessary, including: (i) information pertaining to the denial of unescorted access authorization (UAA) or unescorted access (UA), fitness-for-duty authorization (FFDA), safeguards information access (SGIA) or unescorted access to a nuclear power plant under construction (i.e., construction access (CON)), or unescorted access to an Independent Spent Fuel Storage Installation (i.e., ISFSI access (ISFSI)) to determine whether to certify UAA, grant UA/FFDA to a U. S. NRC-licensed facility and to allow me to maintain such access; or (ii) information pertaining to denial of access to Safeguards Information.
2. With the exception of CHRI collected under 10CFR 73.57, the information collected will only be used for the purposes of determining UAA/UA in accordance with 10 CFR 73.56, Personnel Access Authorization Requirements for Nuclear Power Plants, separate FFDA in accordance with 10 CFR Part 26, Fitness for Duty Programs, access to a nuclear power plant under construction, access to an ISFSI, and/or access to Safeguards Information in accordance with 10 CFR 73.21, 73.22 or 73.23, Protection of Safeguards Information, unless I provide a separate release to the licensee or approved C/V for another purpose. CHRI may only be used for the purposes of determining whether a person is suitable for unescorted access to a nuclear power plant or for access to Safeguards Information, and may not be used for any other purpose.

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PADS CONSENT
3. I understand that evidence of criminal conduct detected during the conduct of a background investigation must be reported to the appropriate law enforcement agency by the licensee or contractor/vendor (C/V).
4. I authorize the use of signed copies of this consent to be used in place of an originally signed consent document.
5. The NRC requires that the information collected be used in determining that an individual is trustworthy, reliable, and fit for duty prior to certifying UAA, granting UA/FFDA, while maintaining UAA/UA; granting access to a nuclear power plant under construction or granting access to an ISFSI; and before granting access to safeguards information. The results of this determination must be available to other NRC licensed facilities.
6. Any of the following actions related to the providing and sharing the personal information is sufficient cause for denial or unfavorable termination of UAA/UA/FFDA, access to a nuclear power plant under construction, access to an ISFSI, and/or access to Safeguards Information:
 
   a. Refusal to provide written consent for the background investigation and/or suitable inquiry;
   b. Refusal to provide information or the falsification of any personal information required under 10 CFR 73.56, Personnel Access Authorization Requirements for Nuclear Power Plants, 10 CFR 26, Fitness-for-Duty Programs, and/or 10 CFR 73.21, 73.22 or 73.23, Protection of Safeguards Information, including, but not limited to, the failure to report any previous denial or unfavorable termination of authorization;
   c. Refusal to provide written consent for the sharing of personal information with other licensees or other entities required under 10 CFR 73.56, Personnel Access Authorization Requirements for Nuclear Power Plants 10 CFR Part 26, Fitness-for-Duty Programs, and/or 10 CFR 73.21, 73.22 or 73.23, Protection of Safeguards Information; and
   d. Failure to report any legal actions in accordance with 10 CFR 73.56(g).
7. I understand that the domestic commercial nuclear industry uses a computerized, restricted-access data system, the Personnel Access Data System (PADS), to share information necessary to process applications of workers for UAA/UA/FFDA/SGIA to nuclear facilities, access to a nuclear power plant under construction, access to an ISFSI, and/or access to Safeguards Information. I further understand that this system is intended to permit nuclear facility licensees and their accepted contractors/vendors to meet regulatory requirements mandating that certain information be available to any facility licensee by retaining certain access information in a central computer database.
8. I understand that the information may be transferred, electronically or otherwise, to other licensees and contractor/vendors or the agents of each. This information will include, but is not limited to:
 
   a. Name and Social Security Number;
   b. Place of birth and physical characteristics;
   c. Dates when any of the following are completed: background investigation, psychological evaluation, fitness-for-duty testing, suitable inquiry checks;
   d. Dates when UAA/UA, access to a nuclear power plant construction site, and/or access to Safeguards Information has been authorized or terminated;
   e. Date of any denial of UAA/UA, access to a nuclear power plant under construction, and/or access to Safeguards Information and the company holding the relevant information;
   f. Dates associated with FFD testing (pre-access, post-event, for cause and follow-up) and treatment;
   g. Annual radiation exposure history;
   h. Respiratory equipment qualification/fit testing;
   i. Medical qualification for respirator use;
   j. Data concerning training required for UAA/UA/FFDA, access to a nuclear power plant construction site, access to an ISFSI, access to Safeguards Information and work qualification; and
   k. Direction to seek additional information directly from another licensee.

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PADS CONSENT
9. I understand that information contained within FBI CHRI obtained for UAA/UA and SGIA purposes will be restricted to the NRC, nuclear licensee facilities regulated by the NRC, and myself, and that the criminal history information will not be released to contractor/vendors or their agents.
10. I authorize any individual, organization, institution, or entity that now has, or obtains in the future, access-related information about me (examples of which are provided in paragraph 8), whether or not such information is included in the PADS database, to release any such information in order to perform the investigation and evaluation required for UAA/UA/FFDA, access to a nuclear power plant construction site, access to an ISFSI, and/or access to Safeguards Information.
11. I authorize the entry into the PADS computer database of any information collected for the purpose of processing my application for, or continued maintenance of, UAA/UA/FFDA, access to a nuclear power plant construction site, access to an ISFSI, and/or access to Safeguards Information. I authorize the transfer of such information, electronically or otherwise, to other NRC nuclear facility licensees and contractors/vendors. I authorize such licensees and contractors/vendors to use the database information for the purpose of determining my eligibility for UAA/UA, for access to a nuclear power plant construction site, access to an ISFSI, for compliance with 10 CFR 810, Assistance to Foreign Atomic Energy Activities, and/or for access to Safeguards Information.
12. I understand that information obtained pursuant to this Consent shall be treated as confidential. The release of access-related information about me shall be limited to regulatory agencies and such employees of NRC facility licensees and their contractors/vendors who have been designated as having a "need to know" the information in order to do their jobs. The following is a listing of individuals that may access information without my consent in order to perform their official duties:
 
   a. Myself or my representative, when I have designated the representative in writing for specified UAA/UA/FFDA, nuclear power plant construction site access, ISFSI access, safeguards information access and/or FFD matters;
   b. Assigned Medical Review Officers (MROs) and MRO staff;
   c. NRC representatives;
   d. Appropriate law enforcement officials under court order;
   e. A licensee, contractor/vendor, or their agents who have a need to have access to the information to perform their assigned duties under the UAA/UA/FFDA program, nuclear power plant construction site access, ISFSI access, safeguards information access, and/or FFD programs, including determinations of fitness, access authorization or FFD program audits, and some human resources functions;
   f. The presiding officer in a judicial or administrative proceeding that is initiated by the subject individual;
   g. Persons deciding matters under access authorization, safeguards or FFD program appeal process; and
   h. Other persons pursuant to court order.
13. I understand that all information about me in the database will be maintained as securely as reasonably practicable for a period of at least 5 years after UAA/UA/FFDA, access to a nuclear power plant construction site, access to an ISFSI, and/or access to Safeguards Information is last terminated. The types of records maintained include documentation collected during the administration of the access authorization, safeguards and FFD programs.
14. All documents pertaining to a 5 year or permanent denial of UAA/UA/FFDA required by 10 CFR Part 26 will be retained by a licensee making the denial or unfavorable termination of UAA/UA/FFDA for 40 years or the NRC determines that the records are no longer needed.
15. The records of FFD training and examinations conducted under 10 CFR Part 26 and 10 CFR 73.21, 73.22, or 73.23 will be maintained for at least 3 years.
16. Records identified are normally maintained at Duke Energy.

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PADS CONSENT
17. I understand that if I determine that in accordance with 28 CFR 16.34, Procedure to obtain change, correction or updating of identification records -- If, after reviewing my identification record, I believe that it is incorrect or incomplete in any respect and wish changes, corrections or updating of the alleged deficiency, I may make application directly to the agency which contributed the questioned information. I may also direct my challenge as to the accuracy or completeness of any entry on my record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency. For information regarding retention and redress of information from the DHS IDENT/HART systems, please refer to the DHS System of Records Notices (SORNs) and HART Privacy Impact Assessment (PIA), and for information regarding the DHS IDENT/HART interoperability with FBI's NGI, please refer to DHS Interoperability PIA found at https://www.dhs.gov/compliance.
18. I understand that I have a right to review information collected and maintained by Duke Energy to assure it is accurate and complete and to correct any inaccurate or incomplete information.
19. I understand that, upon my written request to Duke Energy, and at no cost to me, I will be provided, within 10 business days, with a printed copy of the information about me which is recorded in the Personal Access Data System (PADS) database. If, after my review of such information, I can show that any of the information is incorrect or incomplete, such information will be corrected and/or completed as soon as is reasonably practical.
20. I understand that at any time and upon written notice to Duke Energy, I may withdraw this Consent, but this will also constitute a withdrawal of my request for UAA/UA/FFDA/SGIA/CON/ISFSI. I understand that any processing activities that were initiated before receipt of my withdrawal of consent shall continue, and the resulting information will be retained in the database. No new inquiries shall be initiated after receipt of my withdrawal of consent. Thereafter, licensees and PADS participants are not permitted to retrieve information from the database other than my name, date of birth, identification number, and the fact that my consent has been withdrawn, unless I provide a currently valid Consent or the information sought is required by NRC regulation.
21. I hereby release Duke Energy, other licensees, PADS participants, NEI, and the officers, employees, representatives, agents, and records custodians of each as well as the officers, employees, representatives, agents, and records custodians of any entity or individual supplying or using such information from any and all liability based on their authorized receipt, disclosure, or use of the information obtained pursuant to this Consent and to determine my eligibility for unescorted access authorization/unescorted access to nuclear facilities, access to a nuclear power plant under construction, access to an ISFSI, FFDA and/or access to Safeguards Information.
22. I understand that this Consent is not intended to and does not affect any right or responsibility that I, my employer (if not Duke Energy), or Duke Energy may have under Section 211 of the Energy Reorganization Act of 1974, as amended. I further understand that nothing herein (1) affects my right or my responsibility to bring potential safety concerns to my employer (if not Duke Energy), Duke Energy, or the NRC; or (2) prohibits me from participating in any proceeding or investigation regarding such a potential safety concern.
23. I also understand that information obtained pursuant to this Consent may be disclosed by Duke Energy in a judicial or administrative proceeding arising out of my access to and/or employment at any Duke Energy facility.
24. I have read and understand this Consent and authorize Duke Energy to take such actions as are described herein or specified by PADS procedures. While I understand that UAA/UA/FFDA, access to a nuclear power plant construction site access to an ISFSI, and/or access to Safeguards Information is dependent upon my accepting the regulatory requirements of the UAA/UA/FFDA/SGIA/CON program, the statements made by me in this Consent and my decision to sign this Consent are voluntary. The statements were not induced by any promise nor have I been subjected to any threat, duress or coercion to sign this Consent.

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
INSTRUCTIONS FOR THE COMPLETION OF THE PERSONAL HISTORY QUESTIONNAIRE
Unless otherwise instructed, you are required to complete all portions of this PHQ to be considered for unescorted access authorization, unescorted access, fitness-for-duty authorization, construction access or safeguards information access (UAA/UA/FFDA/CON/SGIA) to a/an Duke Energy nuclear plant. Some questions are followed by requests for additional data. Enter all dates in the format two-digit month, two-digit day and four-digit year (MM/DD/YYYY). After completing and before submitting, review the questionnaire to ensure there are no omissions. This form is self-validating and any field containing an incorrect or missing value will be highlighted in red. For more information on the error, click in a red field and a description of the error will be displayed.
I have read and understand the instructions for filling out this PHQ.
You can only complete the PHQ if you have read and understand the instructions.
I understand that by entering my Secure ID that I am providing my electronic signature.
You can only complete the PHQ if you acknowledge the Secure ID as an electronic signature.
at
Plant Name
on:
Date
Is the UAA/UA/FFDA information above correct?
Please provide corrected information. Note: This is for informational use only. ePHQ will validate data based on the information provided by the plant.
Do you currently maintain UAA/UA/FFDA at a nuclear power plant?
My UAA/UA/FFDA is current at
Plant Name
Last UAA/UA/FFDA was terminated at
Plant Name
on:
Date
Reason
If Yes, last period of access was terminated at
Plant Name
on:
Date
Reason
If Yes, last period of Safeguards Information Access was terminated at
Plant Name
on:
Date
Reason
PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PERSONAL DATA
Provide personal information in blanks provided. Ensure that the telephone number you provide is current in the event you need to be contacted for clarification or for additional information, if necessary.
Last Name
First Name
Middle Name
Suffix
SECURE ID


Are your last name, first name and middle name correct?
Provide your correct information
Last Name
First Name
Middle Name


Other Names
(Maiden name, aliases, nicknames, and when used)
Date of Birth
Country of Citizenship

Place of Birth:
City
State
Country
Are you a United States citizen?
Were you born in the United States?
Port of Entry
Date of Entry
Source (e.g., passport)
Issuing Country
Number
Date of Issue
Expiration Date
Do you have a Visa?
Visa Type
Visa Number
Expiration Date
Reason for No Visa
Are you a citizen of more than one country? (Do not include Country of Citizenship indicated above.)

Country of Citizenship
Country of Citizenship

PERSONAL HISTORY QUESTIONNAIRE (PHQ) AND SELF-DISCLOSURE
PERSONAL DATA
Permanent Address:
Number-Street-Apartment No.
City
State
Zip Code

Country
Telephone number
Extension
To assist in contacting you if additional information is needed, provide as available:
Primary Contact Number
Alternate Contact Number
E-mail address
Personal Description:
Height (ft)
Height (inch)
Weight (lbs)
Eye color
Hair color
Gender M/F
Race
Do you have a valid, unexpired US Driver's license?
US Driver's License Information
Driver license number
State
Expiration date
Do you have a valid, unexpired state-issued ID? Personal History Questionnaire Error

Personal History Questionnaire Error

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